Healthcare Provider Details

I. General information

NPI: 1285708396
Provider Name (Legal Business Name): RIVERVIEW PEDIATRICS AND FAMILY PRACTICE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 05/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10420 US HIGHWAY 301 S
RIVERVIEW FL
33578-5806
US

IV. Provider business mailing address

10420 US HIGHWAY 301 S
RIVERVIEW FL
33578-5806
US

V. Phone/Fax

Practice location:
  • Phone: 813-741-0019
  • Fax: 813-741-3290
Mailing address:
  • Phone: 813-741-0019
  • Fax: 813-741-3290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME98642
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP3184902
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME25434
License Number StateFL

VIII. Authorized Official

Name: MRS. YVONNE JOAN CLARKE
Title or Position: PRES
Credential: ARNP
Phone: 813-741-0019